Our plan to improve the health and wellbeing of older people

A plan for the sector, by the sector

Safer, person-centred healthcare for older people is the main goal of an ambitious five-year plan to integrate and coordinate the health services system in the region.

The PHN and Metro North Hospital and Health Service are working to implement directions from the Five Year Health Care Plan for Older People who live in Brisbane North 2017-22.

Consortia model delivers better outcomes in aged care

Helping people to stay healthy and at home

The PHN leads the healthy@home consortium, a consortium of 18 organisations committed to providing high quality Commonwealth Home Support Program (CHSP) services, helping older people maximise their health and wellbeing and remain living at home.

The healthy@home model emphasises the importance of building and maintaining strong relationships, developing shared goals and common progress measures, a culture of collaboration and a goal of having a broader impact to support the sector and all older people across our region.

CHSP services include domestic assistance, personal care, individual social support, group social support, nursing, allied health, transport and specialised support services.


8279 clients received CHSP services from the healthy@home consortium during 2019/20.




Assessing eligibility for aged care services

The Regional Assessment Service, led by the PHN completed 4,318 assessments for aged care services via our Regional Assessment Service consortium.

Clinical training for aged care nurses

The clinical pathway training project enhanced the clinical knowledge and skills of residential aged care facility nurses. This project aimed to improve the care of residents and build the confidence of RACF nursing staff; aiding their communication with care providers.

A nurse practitioner with expertise in local residential aged care was commissioned to deliver the project, which included training on the management of residents with unstable vital signs; the behavioural symptoms of dementia; falls; recognition of patient deterioration and indwelling urinary catheters.


nursing staff across the Brisbane North region registered their participation in this project. Despite COVID-19 shifting the projects delivery mode to online, training sessions received high attendance numbers.

Due to the overwhelmingly positive feedback, this project was recommissioned for the new financial year to further support local RACF nursing staff.

Exercise program designed for in-home aged care

Keeping active at home

Active at Home is a new evidence-based and ready-to-go exercise program, now available to organisations providing home care to older people anywhere in Australia. During 2019/20, 91 clients received support through Active at Home care workers.

PHN leads sector development

Our annual and quarterly aged care forums are well attended by a diverse range of sector representatives and this helps them to support each other in meeting the challenges of an evolving and complex aged care environment.

During 2019/20, our team held 4 aged care forums, attended by over 806 representatives from across the sector.

As the COVID-19 pandemic began, the PHN Healthy Ageing team adapted swiftly, rolling out their first virtual aged care forum on 19 March 2020, attended by 240 people.

The Aged Care Forum in November 2019, chaired by GOC Care Program Manager, Maria Martakis.


Aboriginal and Torres Strait Islander health and wellbeing